Director, Quality

About This Role

Directing the continuous quality and performance improvement program for the entire hospital is the core of this role. It involves using data analysis to assess performance, focusing on process and systems improvement, and overseeing risk management and patient safety activities. This position suits a leader who can coordinate regulatory readiness and educate staff on quality programs.

Responsibilities

• Provide leadership and oversight of a comprehensive, efficient, and integrated organization-wide Continuous Quality Performance Improvement program
• Measure and assess performance through collection, analyses, and trending of data
• Focus on processes and systems to improve performance
• Direct, facilitate, and report on all aspects of services relating to risk management and patient safety
• Investigate factors contributing to adverse outcomes to improve processes and systems
• Encourage reporting on risk reduction strategies in an atmosphere which minimizes blame or retaliation
• Foster environment to reduce unanticipated adverse events and/or outcomes
• Responsible for education of Continuous Quality and Performance Improvement and additional hospital-wide education and training
• Direct the functions and operation of the hospital-wide continuous quality improvement program including review of records for indicators of quality
• Report findings to leadership, Medical Executive Committee, the Board of Managers and other committees as appropriate
• Responsible for education of Continuous Quality and Performance Improvement to hospital and medical staff
• Annually review hospital-wide plans for the functions of IC and CQPI and establish goals and objectives for the next year
• Act as a liaison to local health officials
• Coordinate inspections and accreditation reviews with state and other regulatory agencies
• Demonstrate knowledge of growth, development, and the aging process for the planning and delivery of age-appropriate care
• Perform other duties as assigned

Requirements

• Clinical license required
• BSN or BS/BA required
• Minimum two (2) years in an acute hospital or rehabilitation setting
• Basic Life Support (BLS/CPR) required
• Data analysis and reporting skills
• CQPI methodologies (e.g., RCA, FMEA, PDSA)
• Risk management and patient safety facilitation skills
• Regulatory/accreditation readiness skills
• Effective teaching, communication, and collaboration skills
• Basic computer knowledge
• Knowledge of basic equipment
• Appropriate telephone communication skills